Form 
4852
(Rev. January 2007)	Substitute for Form W-2, Wage and Tax Statement, or Form 
1099-R, Distributions From Pensions, Annuities, Retirement, or 
Profit Sharing Plans , IRAs, Insurance Contracts, etc.
Attach to Form 1040, 1040A, 1040-EZ, or 1040X	

OMB No. 1545-0074	
1 Type or print your first name and middle initial.
	Last name	2 Social security number (SSA)	
3 Address
	
4 Enter year in space provided and check one box. For the tax year ending December 31, _________
I have been unable to obtain (or have received an incorrect)     Form W-2 OR    Form 1 099-R.
I have notified the IRS of this fact. The amounts shown on line 7 or line 8 are my best estimates for all wages or payments made to me and tax withheld by my employer or payer named on line 5.	
5.  Employer’s or payer’s name, address, and ZIP code
	6  Employer’s or payer’s identification number (if known)
	
7         Form W-2. Enter wages, tips, other compensation, and taxes withheld.	
a	Wages, tips, and other compensation		g	State income tax withheld		
b	Social security wages			(Name of state)________		
c	Medicare wages and tips		h	Local income tax withheld		
d	Advance EIC payment			(Name of locality) ________		
e	Social security tips		i	Social security tax withheld		
f	Federal income tax withheld		J	Medicare tax withheld		
8         Form 1099-R. Enter Distributions from pensions, annuities, retirement/profit –sharing plans, IRSs, insurance contracts	
a	Gross distribution		f	Federal income tax withheld		
b	Taxable amount		g	State income tax withheld		
c	Taxable amount not determined		h	Local income tax withheld		
d	Total distribution		I	Employee contributions		
e	Capital gain (included in 8b)		j	Distribution codes		
9 How did you determine the amounts on lines 7 and 8 above?

10 Explain your efforts to obtain Form W-2, Form 1099-R, or Form W-2c, Corrected Wage and Tax Statement.

Sign
Here
	Under penalty of perjury from WITHOUT the “United States” and from within the “United States” of America and a foreign state pursuant to 28 U.S.C. §1746(1), I declare that I have examined this statement, and to the best of my knowledge and belief, it is true, correct, and complete

Signature: ______________________________________________ Date: __________________	

Purpose of form. Form 4852 serves as a substitute for Forms W-2, W-2c, and 1 099-R and is completed by taxpayers or their representatives when (a) their employer or payer does not give them a Form W-2 or Form 1 099-R, or (b) when an employer or payer has issued an incorrect Form W-2 or Form 1 099-R. Attach this form to your income tax return.
You should always attempt to get Form W-2 or Form 1099-R from your employer or payer before contacting the IRS or filing Form 4852. After February 14, you may call the IRS at 1-800-829-1040 if you still have not received Form W-2 or Form 1099-R. Generally, do not file Form 4852 before April 15.
If you received an incorrect Form W-2 or Form 1 099-R, you should always attempt to have your employer or payer issue a corrected form before filing Form 4852.
Note. Retain a copy of Form 4852 for your records. Check your Social Security Statement (received at least a full year after the date shown on line 4) against Form 4852. If the earnings you reported on Form 4852 are not shown in the statement, you should contact the Social Security Administration (SSA) at the telephone number shown on the statement. Alternatively, after
September 30 following the date shown on line 4, you may contact your local SSA office to verify wages reported by your employers.
Will I need to amend my return? If you receive a Form W-2, Form W-2c, or Form 1 099-R, after your return is filed with Form 4852, and the information differs from the information reported on your return, you must amend your return by filing Form 1040X, Amended U.S. Individual Income Tax Return.
Penalties. The IRS will challenge the claims of individuals who attempt to avoid or evade their federal tax liability by using Form 4852 in a manner other than as prescribed. Potential penalties for the improper use of Form 4852 include:
● Accuracy-related penalties equal to 20 percent of the amount of taxes that should have been paid,
● Civil fraud penalties equal to 75 percent of the amount of taxes that should have been paid, and
● A $5,000 civil penalty for filing a frivolous return or submitting a specified frivolous submission as described by section 6702 of the Internal Revenue Code.